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Date Rec' d
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
,4-,/6
3'7()
/h.J~
1 White
Pink
Yellow
I PERMITNO.~
File
City
Applicant
s~
ZONING (office use)
~-Z--
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
(Name)
~C-#o~
(Address)
(Phone)
9S2-- y:Yo-z... 71.3
S~
BUILDER
(Company Name)
(Contact Name)
(Address)
(Phone)
(Phone)
TYPE OF WORK 0 New Construction ODeck o Porch "5(Re-Roofing ORe-Siding OLower Level Finish 0 Fireplace
OAddition OAlteration OUtility Conn&
CODE: OI.R.C. OI.B.C.
Type of Construction:
Occupancy Group: A B
Division:
I
E
II
F
I
III
H
2
IV V
I M
3 4
o Mise.
A
R
5
B
S
U
PROJECT COST IV ALUE $
(excluding land)
hat I have furnished mformatlOn on this applicatlOn which IS to the best of my knowledge true and correct. I also certify that I am the owner or authonzed agent tllr the
property and that all construction WIll conform to all eXlstmg state and local laws and wIll procecd in accordance with submItted plans I am aware that the buildmg
Jke t is permil for Ju;t cause Furt ore, I hereby agree that the CIty official or a deSignee may enter upon the properry to perform needed mspectlllns
/O//O/{}b
Contractor's License No. ' D~te
x
Permit Valuation
Permit Fee
$
$
$
$
$
$
$
$
\,v-)
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
This
Gas Fireplace P rmit Fee
\D (0 ~
Date
-
Park Support Fee # $
SAC # $
Water Meter Size 5/8"; I"; $
Pressure Reducer $
Sewer/Water Connection Fee # $
Water Tower Fee # $
Builder's Deposit $
Other $
TOTAL DUE $ --r(/t . .,,-
'....
Paid
Date
Receipt No.
By
ThIS IS to certIfy that the request In the above applicatIOn and accompanymg documents is m accordance wIth the City Zonmg Ordinance and may proceed as requested. ThIS document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence Before occupancy, a Certificate of Occupancy must be
isslled
Planning Director
Special Conditions, if any
Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372